Housing First


Housing First is a relatively recent innovation in human service programs and social policy regarding treatment of people who are homeless and is an alternative to a system of emergency shelter/transitional housing progressions. Rather than moving homeless individuals through different "levels" of housing, whereby each level moves them closer to "independent housing", Housing First moves the homeless individual or household immediately from the streets or homeless shelters into their own accommodation.
Housing First approaches are based on the concept that a homeless individual or household's first and primary need is to obtain stable housing, and that other issues that may affect the household can and should be addressed once housing is obtained. In contrast, many other programs operate from a model of "housing readiness" — that is, that an individual or household must address other issues that may have led to the episode of homelessness prior to entering housing.

General principles

Housing First is an approach that offers permanent, affordable housing as quickly as possible for individuals and families experiencing homelessness, and then provides the supportive services and connections to the community-based supports people need to keep their housing and avoid returning to homelessness. The principles behind this approach are:
  1. Move people into housing directly from streets and shelters without preconditions of treatment acceptance or compliance;
  2. The provider is obligated to bring robust support services to the housing. These services are predicated on assertive engagement, not coercion;
  3. Continued tenancy is not dependent on participation in services;
  4. Units targeted to most disabled and vulnerable homeless members of the community;
  5. Embraces harm-reduction approach to addictions rather than mandating abstinence. At the same time, the provider must be prepared to support resident commitment to recovery;
  6. Residents must have leases and tenant protections under the law;
  7. Can be implemented as either a project-based or scattered site model.

    History and evolution

In Los Angeles, California, in 1988, the "Housing First" Program for families was launched at Beyond Shelter by Tanya Tull in response to a sharp increase in the number of homeless families with children. The "housing first" approach for families includes in-depth screening and assessment for child safety. Families should not be relocated to rental housing if there are indicators that a child might be in danger. In "housing first" for families, services are available before, during, and after relocation to rental housing - but engagement is not a requirement for participation. Unfortunately the "housing first" philosophy was often misinterpreted in later years and, today, many government programs promote faulty application of "housing first." For households with children, appropriate services and monitoring may be delivered through home visits, outpatient treatment, or linking to appropriate services in the community at-large.
In 1992 Dr. Sam Tsemberis, a faculty member of the Department of Psychiatry of the New York University School of Medicine, founded Pathways to Housing in New York City. Housing First for the chronically homeless is premised on the notion that housing is a basic human right, and so should not be denied to anyone, even if they are abusing alcohol or other substances. The Housing First model, thus, is philosophically in contrast to models that require the homeless to abjure substance-abuse and seek treatment in exchange for housing.
Housing First, when supported by the United States Department of Housing and Urban Development, does not only provide housing. The model, used by nonprofit agencies throughout America, also provides wraparound case management services to the tenants. This case management provides stability for homeless individuals, which increases their success. It allows for accountability and promotes self-sufficiency. The housing provided through government supported Housing First programs is permanent and "affordable," meaning that tenants pay 30% of their income towards rent. Housing First, as pioneered by Pathways to Housing, targets individuals with disabilities. This housing is supported through two HUD programs. They are the Supportive Housing Program and the Shelter Plus Care Program. Pathways' Housing First model has been recognized by the Substance Abuse and Mental Health Services Administration as an Evidence-based practice.
The Housing First Model is executed through either a scattered-site or project-based implementation. A scattered-site Housing First program is a model in which residents are offered the opportunity of being housed in individual housing units throughout a community. This model integrates participants in a community as opposed to assembling multiple or all participants in one project or location. In a project-based Housing First implementation, residents are offered units within a single housing project or site. This model congregates multiple or all participants in one locality. In both the scattered-site and project-based Housing First programs, residents are given access to a wide variety of supportive health and rehabilitation services which they have the option, although not mandatory, to participate in and receive treatment.
Housing First is currently endorsed by the United States Interagency Council on Homelessness as a "best practice" for governments and service-agencies to use in their fight to end chronic homelessness in America.
Housing First programs currently operate throughout the United States in cities such as New Orleans, Louisiana; Plattsburgh, New York; San Diego, California;; Anchorage, Alaska; Salisbury, Maryland; Minneapolis, Minnesota; New York City; District of Columbia; Denver, Colorado; San Francisco, California; Atlanta, Georgia; Chicago, Illinois; Portland, Maine; Quincy, Massachusetts; Philadelphia, Pennsylvania; Salt Lake City, Utah; Seattle, Washington; ; Austin, Texas; and Cleveland, Ohio

Evidence and outcome

In Massachusetts, the Home & Healthy for Good program reported some significant outcomes that were favorable especially in the area of cost savings.
The Denver Housing First Collaborative, operated by the Colorado Coalition for the Homeless, provides housing through a Housing First approach to more than 200 chronically homeless individuals. A 2006 cost study documented a significant reduction in the use and cost of emergency services by program participants as well as increased health status. Emergency room visits and costs were reduced by an average of 34.3 percent. Hospital inpatient costs were reduced by 66 percent. Detox visits were reduced by 82 percent. Incarceration days and costs were reduced by 76 percent. 77 percent of those entering the program continued to be housed in the program after two years.
Researchers in Seattle, Washington, partnering with the Downtown Emergency Service Center, found that providing housing and support services for homeless alcoholics costs taxpayers less than leaving them on the street, where taxpayer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation appeared in the Journal of the American Medical Association April, 2009. This first US controlled assessment of the effectiveness of Housing First specifically targeting chronically homeless alcoholics showed that the program saved taxpayers more than $4 million over the first year of operation. During the first six months, even after considering the cost of administering the housing, 95 residents in a Housing First program in downtown Seattle, the study reported an average cost-savings of 53 percent—nearly US $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, stable housing also results in reduced drinking among homeless alcoholics.
In Utah, there has been "a 72 percent decrease overall since enacting the plan in 2005" according to the Utah Division of Housing and Community Development.
In August 2007, the US Department of Housing and Urban Development reported that the number of chronically homeless individuals living on the streets or in shelters dropped by an unprecedented 30 percent, from 175,914 people in 2005 to 123,833 in 2007. This was credited in part to the "housing first" approach; Congress in 1999 directed that HUD spend 30% of its funding on the method.
In September 2010, it was reported that the Housing First Initiative had significantly reduced the chronic homeless single person population in Boston, Massachusetts, although homeless families were still increasing in number. Some shelters were reducing the number of beds due to lowered numbers of homeless, and some emergency shelter facilities were closing, especially the emergency Boston Night Center. By 2015, Boston Mayor Marty Walsh had announced a 3-year plan to end chronic homelessness, focusing on coordinating efforts among public agencies and nonprofit organizations providing services to homeless men and women.
In 2013, the estimated national public cost of chronic homelessness was between $3.7 and $4.7 billion according to the United States Interagency Council on Homelessness. Through Housing First programs, chronically homeless individuals are using fewer hospital resources, spending less time in costly incarceration and requiring fewer emergency room visits. For example, a review of the impact of permanent supportive housing and case management on the health of the chronically homeless found evidence that these services have a positive impact on health outcomes such as self-reported mental health status and substance use, a large impact on health care utilization, and a reduction in Medicaid health care costs. Studies in New York City and in Utah have shown that every homeless person housed in programs such as Housing First saves taxpayers $10,000 and $8,000 a year, respectively. A research study at University of Northern Carolina also reported that a housing project for the chronically homeless called Moore Place had saved the county $2.4 million.
The implementation of Housing First philosophy when working with homeless families and young adults has been shown to increase clients' enrollment in public assistance benefits, decrease involvement in the child welfare system, and have very few returning to homelessness.
When comparing the effects of Housing First on older and younger homeless adults, older homeless adults have shown significantly higher rates of improvement in areas like mental component summary scores, condition specific quality of life, mental health symptom severity, and percentage of days stably housed.
When comparing the effects of Housing First on homeless adults with lower or borderline intellectual functioning to homeless adults with normal intellectual functioning it has been shown that there is no significant difference.

Post–2007 U.S. policy and legislation

The United States Congress appropriated $25 million in the McKinney-Vento Homeless Assistance Grants for 2008 to show the effectiveness of Rapid Re-Housing programs in reducing family homelessness.
In February 2009, President Obama signed the American Recovery and Reinvestment Act of 2009, part of which addressed homelessness prevention, allocating $1.5 billion for a Homeless Prevention Fund. The funding for it was called the "Homelessness Prevention and Rapid Re-Housing Program", and was distributed using the formula for the Emergency Shelter Grants program.
On May 20, 2009, President Obama signed the Homeless Emergency Assistance and Rapid Transition to Housing Act into Public Law, reauthorizing HUD's Homeless Assistance programs. It was part of the Helping Families Save Their Homes Act of 2009. The HEARTH act allows for the prevention of homelessness, rapid re-housing, consolidation of housing programs, and new homeless categories. In the eighteen months after the bill's signing, HUD must make regulations implementing this new McKinney program.
In late 2009, some homeless advocacy organizations, such as the National Coalition for the Homeless, reported and published perceived problems with the HEARTH Act of 2009 as a HUD McKinney-Vento Reauthorization bill, especially with regard to privacy, definitional ineligibility, community roles, and restrictions on eligibile activities.
On June 22, 2010, the United States Interagency Council on Homelessness presented Opening Doors: Federal Strategic Plan to Prevent and End Homelessness to the Obama Administration and Congress. This is the nation's first comprehensive strategy as mandated by the HEARTH Act and includes Housing First as a best practice for reaching the goal of ending chronic homelessness by 2015.
On June 11, 2014, the 100,000 Homes Campaign in the United States, launched in 2010 to "help communities around the country place 100,000 chronically homeless people into permanent supportive housing", announced that it reached its four-year goal of housing 100,000 chronically homeless people nearly two months before its July 29 deadline.
New York Times journalist David Bornstein summarized key elements of the 100,000 Homes Campaign that campaign leaders attribute to its success. This included learning individual homeless people's "name and need" by mobilizing volunteers to go very early in the morning to check on them, establishing a "vulnerability index" so they could prioritize certain homeless people and "bring housing advocates and agency representatives together to streamline the placement processes, and share ideas about how to cut through red tape."

Application to family homelessness

The Housing First methodology was initially developed in 1988 in Los Angeles, California, to address an increase in family homelessness. The basic methodology helps homeless families to relocate from shelters and transitional housing directly into permanent rental housing in the community at-large as quickly as possible, with home-based case management support for a traditional period of time. In other words, the services traditionally being provided in transitional housing were instead provided to families after they had been assisted in relocating to permanent housing at rents they could afford. This was a major innovation in the field at the time. The basic premise was that families were more responsive to interventions and support from a stable permanent housing base than while still homeless. In the 2009 HEARTH Act, the Housing First approach to ending homelessness was codified into law. Housing First programs for families differ dramatically from Housing First for the chronically homeless, as children are involved. Beyond Shelter's leadership promoted this new approach across the country for the next 20 years, working collaboratively with the National Alliance to End Homelessness.

Outside the United States

Australia

In South Australia, the State Government of Premier Mike Rann committed substantial funding to a series of initiatives designed to combat homelessness. Advised by Social Inclusion Commissioner David Cappo and the founder of New York's Common Ground program, Rosanne Haggerty, the Rann Government established Common Ground Adelaide, building high quality inner city apartments for "rough sleeping" homeless people. The government also funded the Street to Home program and a hospital liaison service designed to assist homeless people who are admitted to the emergency departments of Adelaide's major public hospitals. Rather than being released back into homelessness, patients identified as rough sleepers are found accommodation backed by professional support. Common Ground and Street to Home now operate across Australia in other states.
The "Street to Home" and "Common Ground" projects have been shown to produce similar results to the US Housing First model in terms of strong housing outcomes and reductions in intensity and frequency of service use relative to pre-intervention levels.

Canada

In its Economic Action Plan 2013, the Federal Government of Canada proposed $119 million annually from March 2014 until March 2019—with $600 million in new funding—to renew its Homelessness Partnering Strategy. In dealing with homelessness in Canada, the focus is on the Housing First model. Thus, private or public organizations across Canada are eligible to receive HPS subsidies to implement Housing First programs. In 2008, the Federal Government of Canada funded a five-year demonstration program, the At Home/Chez Soi project, aimed at providing evidence about what services and systems best help people experiencing serious mental illness and homelessness. Launched in November 2009 and ending in March 2013, the At Home/Chez Soi project was actively addressing the housing need by offering Housing First programs to people with mental illness who were experiencing homelessness in five cities: Vancouver, Winnipeg, Toronto, Montréal and Moncton. In total, At Home/Chez Soi has provided more than 1,000 Canadians with housing.
Housing First has grown in popularity in Canada and used in many Canadian ten-year plans to end homelessness, such as those in Edmonton and Calgary, Alberta. Housing First: A Canadian Perspective is spearheaded by Pathways to Housing Calgary and director Sue Fortune. Canadian adaptations to Housing First have demonstrated positive outcomes as documented on the website: www.thealex.ca. Canadian implementations of Housing First must be tailored to Canadian homelessness, resources, politics and philosophy.
In Calgary, Alberta, the Alex Pathways to Housing Calgary which opened in 2007, has 150 individuals in scatter site homes in 2013. Clients pay 30 percent of their income towards their rent: 85 percent of Pathways to Housing clients receive Assured Income for the Severely Handicapped benefits and 15 percent receive . The Alex Pathways to Housing uses a Housing First model, but it also uses Assertive Community Treatment, an integrated approach to healthcare where clients access a team of "nurses, mental health specialists, justice specialists and substance abuse specialists." Director Sue Fortune is committed to the 10 Year Plan To End Homelessless in the Calgary Region. Fortune reported that the Housing First approach resulted in a 66 percent decline in days hospitalized, a 38 percent decline in times in emergency room, a 41 percent decline in EMS events, a 79 percent decline in days in jail and a 30 percent decline in police interactions. Sue Fortune, Director of Alex Pathways to Housing in Calgary in her 2013 presentation entitled "Canadian Adaptations using Housing First: A Canadian Perspective" argued that less than 1% of existing clients return to shelters or rough sleeping; clients spend 76% fewer days in jail; clients have 35% decline in police interactions.
Pathways to Housing Canada describes the Housing First as a "client-driven strategy that provides immediate access to an apartment without requiring initial participation in psychiatric treatment or treatment for sobriety."
Following the development of several Housing First programs through the Home/Chez Soi research project, an initiative to provide Housing First training and technical assistance was created and has been shown to be useful in developing high fidelity programs.

Denmark

In Denmark, Housing First is embedded in the national Homeless Strategy as the overall strategy. However, it has been shown that this intervention strategy is serving only a small number of people recorded to be homeless which is most likely due to barriers like shortage of affordable housing.

Finland

In 2007 the centre-right government of Matti Vanhanen began a special program of four wise men to eliminate homelessness in Finland by 2015.
The programme to reduce long-term homelessness targets just some homeless people. Assessed on the basis of social, health and financial circumstances, this is the hard core of homelessness. The programme to reduce long-term homelessness focuses on the 10 biggest urban growth centres, where most of the homeless are to be found. The main priority, however, is the Helsinki Metropolitan Area, and especially Helsinki itself, where long-term homelessness is concentrated.
The programme is structured around the housing first principle. Solutions to social and health problems cannot be a condition for organising accommodation: on the contrary, accommodation is a requirement which also allows other problems of people who have been homeless to be solved. Having somewhere to live makes it possible to strengthen life management skills and is conducive to purposeful activity.
Because of all the reasons there are for long-term homelessness, if it is to be cut there need to be simultaneous measures at different levels, i.e. universal housing and social policy measures, the prevention of homelessness and targeted action to reduce long-term homelessness.
The programme’s objectives are:
The French government launched a Housing First-like program in France in 2010 in 4 major cities - Toulouse, Marseille, Lille and Paris - called "Un chez-Soi d'abord". It follows the same principles as the Canadian and US programs: it is focused on homeless people with mental illness or addicted to drugs or alcohol. The plan is on a three-year basis for each individual, living in accommodation provided by an NGO.
Clients are given any needed help with social issues and medical care. The first houses have been working in three cities since 2011 and a hundred apartments have been planned in Paris starting in May 2012.
Several NGOs are involved in this trial. They provide rental management and social support for tenants.
Those NGOs are linked with scientists investigating the results of the experiment and serve as a relay for information and status reports on the targeted public. The lead team of "Un chez-soi d'abord" is expecting results to be published around 2017.

Japan

Though homeless support groups like non-profit organization :ja:自立生活サポートセンター・もやい|Moyai, :ja:ビッグイシュー|Bigissue, Médecins du Monde Japan have requested Housing First, Japanese government does not have a Housing First program yet. Traditionally, the government offers public housing for low-income people by public housing law, run by local government. Rent fees are adjusted according to household income. Because applicants must be selected by lottery, low-income people are not guaranteed to be chosen to live in the housing, although they have an advantage. There are a couple of Housing First-like programs. Non-profit organization Littleones renovates discarded or empty homes and they rent the rooms to single mothers with financial and occupational support. The Tsukuroi Tokyo fund advocates Housing First, and they built a shelter specifically for homeless people.

United Kingdom

The U.K. government announced plans for a Housing First pilot programme in the West Midlands, Liverpool, and Manchester, along with funding of £28m. This followed publication of a report entitled Housing First by the Centre for Social Justice which cited the results from the Finnish application of Housing First.

Miscellaneous

As part of the H2020 research project "HOME_EU: Reversing Homelessness in Europe" by the European Commission, approximately 5600 surveys have been conducted between March and December 2017 in France, Ireland, Italy, the Netherlands, Portugal, Spain, Poland, and Sweden in order to understand people's knowledge, attitudes, and practices about homelessness and how much support the general public has in regards to Housing First as a solution for homelessness in Europe.

Criticism of Housing First

One-size-fits-all

professor Ralph DaCosta Nunez, the president and chief executive officer of the Institute for Children, Poverty and Homelessness, calls Housing First "one-size-fits-all" and claims statistics in New York City prove it is destined to fail. Nunez believes that Housing First is "all that's left after the other poverty fighting programs have been underfunded or eliminated." Nunez instead advocates a three-tiered approach to addressing homelessness with Housing First as its first component.

Following Panelák: a failed communist model

Sharam Kohan, a social policy expert and economist, compared the Housing First model to Panelák of the former communist countries that tried to end homelessness by providing permanent and unconditional public housing. Dr. Kohan criticized Housing First model for following Panelák's failed philosophy and approaches. Dr. Kohan points to a growing number of reports from communities that have implemented Housing First programs which are "credited with creating slums and slumlord."

Limits of evidence based policy

On July 31, 2011, Prof. Victoria Stanhope, Ph.D., of New York University School of Social Work and Prof. Kerry Dunn, J.D., Ph.D., of University of New England School of Social Work, published “The curious case of Housing First; The limits of evidence-based policy” in the International Journal of Law and Psychiatry. Drs. Stanhope and Dunn gave an overview of evidence-based policy and presented “critiques based on its reliance on positivist methods and technical approach to policy making. Using these critiques as a framework, the paper discusse the case of Housing First, a policy adopted by the Bush Administration in order to address the problem of chronic homelessness.” According to Drs. Stanhope and Dunn, the Housing First “is an example of research-driven policy making but also resulted in a progressive policy being promoted by a conservative administration. In discussing the case, the paper elaborates on the relationship between evidence and policy, arguing that evidence-based policy fails to integrate evidence and values into policy deliberations. The paper concludes with alternative models of policy decision-making and their implications for research.”
Housing First has been criticized on its failure to address broader service outcomes, namely substance abuse. These criticisms have been rebutted on the grounds that Housing First is a program to end homelessness not to reduce substance abuse, though more recent research indicates it is more effective than traditional approaches in this regard as well. This exchange highlights the way in which the selection of outcomes sets both the terms of the debate and the parameters of “what works.” Embedded in that mantra are a priori decisions about what constitutes working and for whom; in this case it was stable housing for the chronic homeless.
According to Stanhope, Housing First “asserts a right to housing. Such a material right is an anathema to neoliberal ideology and challenges deeply held beliefs that have shaped US welfare from its inception: That no one has a right to a government benefit unless they have proved themselves to be deserving or worthy, or have earned it.”
In a rapid review and document analysis of Housing First scholarly literature in the U.S. and Canada, it has been shown that these literature are severely lacking in the implementation and explicit mention of Harm Reduction.